Friday, March 27, 2015

Alcohol and Addiction: The False Premise of Alcoholics Anonymous

Alcohol is a substance that can generate a craving that can lead to high levels of consumption and unhealthy consequences.  The conventional wisdom about how to address abusive use of alcohol is informed more by folklore than evidence-based science.

Gabrielle Glaser provides an interesting summary of what is known about the condition and treatment of alcohol abuse in an article in The Atlantic: The False Gospel of Alcoholics Anonymous.  For some reason the online version of the article was instead titled The Irrationality of Alcoholics Anonymous

Glaser provides some history related to alcohol abuse and the founding of Alcoholics Anonymous (AA).  In 1935, Bill Wilson, an extremely heavy drinker (“known to drink two quarts of whiskey a day”), managed to stop drinking for good.  He viewed his experience as the model for others to follow, combined that with a healthy dose of man-as-sinner religiosity, and formulated the “12 steps” to follow to recovery. 

“Alcoholics Anonymous was established in 1935, when knowledge of the brain was in its infancy. It offers a single path to recovery: lifelong abstinence from alcohol. The program instructs members to surrender their ego, accept that they are ‘powerless’ over booze, make amends to those they’ve wronged, and pray.”

The approach provided by AA quickly became embedded in the national consciousness as the one and only path to follow in dealing with alcohol abuse.

“A public-relations specialist and early AA member named Marty Mann worked to disseminate the group’s main tenet: that alcoholics had an illness that rendered them powerless over booze. Their drinking was a disease, in other words, not a moral failing. Paradoxically, the prescription for this medical condition was a set of spiritual steps that required accepting a higher power, taking a ‘fearless moral inventory,’ admitting ‘the exact nature of our wrongs,’ and asking God to remove all character defects.”

“Mann helped ensure that these ideas made their way to Hollywood. In 1945’s The Lost Weekend, a struggling novelist tries to loosen his writer’s block with booze, to devastating effect. In Days of Wine and Roses, released in 1962, Jack Lemmon slides into alcoholism along with his wife, played by Lee Remick. He finds help through AA, but she rejects the group and loses her family.”

In 1970 the federal government recognized alcoholism as a disease and passed an act (referred to as the Hughes Act) that set up funding for the study and treatment of alcoholism.  The AA system was viewed as the model for treatment and other approaches that might have been suggested were discriminated against.  The result was that people were now in a position to make money treating people who were having trouble controlling a drinking problem.

“After the Hughes Act was passed, insurers began to recognize alcoholism as a disease and pay for treatment. For-profit rehab facilities sprouted across the country, the beginnings of what would become a multibillion-dollar industry. (Hughes became a treatment entrepreneur himself, after retiring from the Senate.) If Betty Ford and Elizabeth Taylor could declare that they were alcoholics and seek help, so too could ordinary people who struggled with drinking. Today there are more than 13,000 rehab facilities in the United States, and 70 to 80 percent of them hew to the 12 steps, according to Anne M. Fletcher, the author of Inside Rehab, a 2013 book investigating the treatment industry.”

The problem is that there is no independent data to support AA’s claim that:

“….AA has worked for 75 percent of people who have gone to meetings and ‘really tried.’ It says that 50 percent got sober right away, and another 25 percent struggled for a while but eventually recovered. According to AA, these figures are based on members’ experiences.”

Others have investigated this claim and have found no supporting evidence.

“In 2006, the Cochrane Collaboration, a health-care research group, reviewed studies going back to the 1960s and found that ‘no experimental studies unequivocally demonstrated the effectiveness of AA or [12-step] approaches for reducing alcohol dependence or problems.”

“In his recent book, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, Lance Dodes, a retired psychiatry professor from Harvard Medical School, looked at Alcoholics Anonymous’s retention rates along with studies on sobriety and rates of active involvement (attending meetings regularly and working the program) among AA members. Based on these data, he put AA’s actual success rate somewhere between 5 and 8 percent. That is just a rough estimate, but it’s the most precise one I’ve been able to find.”

The sad part about this state of affairs is that there have long been other options available that allow people to control their drinking habits without the extremely difficult step of total abstinence for life.

“The 12 steps are so deeply ingrained in the United States that many people, including doctors and therapists, believe attending meetings, earning one’s sobriety chips, and never taking another sip of alcohol is the only way to get better. Hospitals, outpatient clinics, and rehab centers use the 12 steps as the basis for treatment. But although few people seem to realize it, there are alternatives, including prescription drugs and therapies that aim to help patients learn to drink in moderation. Unlike Alcoholics Anonymous, these methods are based on modern science and have been proved, in randomized, controlled studies, to work.”

To indicate how other countries have used science-based methods to obtain better results, Glaser went to Finland, a heavy drinking country, where the approach used is based on the work of the American neuroscientist John David Sinclair.  Sinclair moved to Finland in the 1970s to take advantage of a unique opportunity:

“….the chance to work in what he considered the best alcohol-research lab in the world, complete with special rats that had been bred to prefer alcohol to water.”

Perhaps Sinclair’s most interesting finding was that people who developed an uncontrollable craving for alcohol were being driven by specific chemical processes in the brain.

“Sinclair came to believe that people develop drinking problems through a chemical process: each time they drink, the endorphins released in the brain strengthen certain synapses. The stronger these synapses grow, the more likely the person is to think about, and eventually crave, alcohol—until almost anything can trigger a thirst for booze, and drinking becomes compulsive.”

He administered types of chemicals called opioid antagonists to his “alcoholic” rats and discovered that these drugs that block opiate receptors could limit the alcohol consumption in rats.  The same effects were found in humans.

“Subsequent studies found that an opioid antagonist called naltrexone was safe and effective for humans, and Sinclair began working with clinicians in Finland. He suggested prescribing naltrexone for patients to take an hour before drinking. As their cravings subsided, they could then learn to control their consumption. Numerous clinical trials have confirmed that the method is effective, and in 2001 Sinclair published a paper in the journal Alcohol and Alcoholism reporting a 78 percent success rate in helping patients reduce their drinking to about 10 drinks a week. Some stopped drinking entirely.”

Three clinics have been established in Finland, and one in Spain, based on Sinclair’s methods.

“In the past 18 years, more than 5,000 Finns have gone to the Contral Clinics for help with a drinking problem. Seventy-five percent of them have had success reducing their consumption to a safe level.”

“The most common course of treatment involves six months of cognitive behavioral therapy, a goal-oriented form of therapy, with a clinical psychologist. Treatment typically also includes a physical exam, blood work, and a prescription for naltrexone or nalmefene, a newer opioid antagonist approved in more than two dozen countries.”

When Glaser asked what the cost of such treatment she was given a figure of about $2,500,

“….a fraction of the cost of inpatient rehab in the United States, which routinely runs in the tens of thousands of dollars for a 28-day stay.”

So tightly fixed in the American mind is the efficacy of the AA approach that results of medical studies are largely ignored.

“….naltrexone has been found to reduce drinking in more than a dozen clinical trials, including a large-scale one funded by the National Institute on Alcohol Abuse and Alcoholism that was published in JAMA in 2006. The results have been largely overlooked. Less than 1 percent of people treated for alcohol problems in the United States are prescribed naltrexone or any other drug shown to help control drinking.”

Even the drug companies seemed sufficiently intimidated by the conventional wisdom to forego marketing drugs that should have been good moneymakers for them.

“Stephanie O’Malley, a clinical researcher in psychiatry at Yale who has studied the use of naltrexone and other drugs for alcohol-use disorder for more than two decades, says naltrexone’s limited use is ‘baffling’.”

“’There was never any campaign for this medication that said, “Ask your doctor,”’ she says. ‘There was never any attempt to reach consumers.’ Few doctors accepted that it was possible to treat alcohol-use disorder with a pill. And now that naltrexone is available in an inexpensive generic form, pharmaceutical companies have little incentive to promote it.”

Glaser hopes that the implementation of the Affordable Care Act (Obamacare) will force a reconsideration of treatments that can be supported in an environment where results and cost-effectiveness are critical.

“The debate over the efficacy of 12-step programs has been quietly bubbling for decades among addiction specialists. But it has taken on new urgency with the passage of the Affordable Care Act, which requires all insurers and state Medicaid programs to pay for alcohol- and substance-abuse treatment, extending coverage to 32 million Americans who did not previously have it and providing a higher level of coverage for an additional 30 million.”

“Nowhere in the field of medicine is treatment less grounded in modern science. A 2012 report by the National Center on Addiction and Substance Abuse at Columbia University compared the current state of addiction medicine to general medicine in the early 1900s, when quacks worked alongside graduates of leading medical schools.”

Alcoholics Anonymous has helped many people, but its method is inappropriate as a first option when science has provided us with evidence that other approaches are more effective.

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